History and Physical — Patient 54

History

Present Illness: A 55 year old woman with hypertension and hypothyroidism was admitted to the Neurology Service at the Methodist Hospital for urgent evaluation of visual loss, diplopia and weakness of the lower extremities. Two weeks ago, she noted the painless onset of blurred vision in the right eye, which has not significantly progressed. Five days ago, she developed double vision, which has worsened. She cannot attribute any change in diplopia to a particular direction of gaze, but reports that the two visual images are typically side-by-side (i.e. horizontal diplopia) in all positions. She denies associated eye pain or discomfort, headache, dysarthria, dysphagia, or confusion. She has never experienced such symptoms in the past.

A 55 year old woman with hypertension and hypothyroidism was admitted to the Neurology Service at the Methodist Hospital for urgent evaluation of visual loss, diplopia and weakness of the lower extremities. Two weeks ago, she noted the painless onset of blurred vision in the right eye, which has not significantly progressed. Five days ago, she developed double vision, which has worsened. She cannot attribute any change in diplopia to a particular direction of gaze, but reports that the two visual images are typically side-by-side (i.e. horizontal diplopia) in all positions. She denies associated eye pain or discomfort, headache, dysarthria, dysphagia, or confusion. She has never experienced such symptoms in the past.

On the day of admission, the patient was examined by an ophthalmologist, who suspected an acutely evolving disorder of the nervous system, and referred her for urgent evaluation.

Past Medical History:

  • Traumatic head injury in 1992 from a weather balloon accident, without loss of consciousness. At this time the patient suffered a left orbital injury associated with mildly decreased visual acuity and an irregular fixed pupil in the left eye, which has not changed.
  • Hypertension, long-standing
  • Hypothyroidism
  • Depression
  • Asthma
  • The patient has been hospitalized four times in the past year for nausea and vomiting. According to the patient, her medical evaluations were unremarkable, and she was given a presumptive diagnosis of gastritis. Her nausea has decreased, but her appetite is poor, and she has lost 20 pounds in the past two months.
  • Hysterectomy 20 years ago for endometriosis; no blood transfusions.

Allergies: No known drug allergies.

Medications: Metoclopramide (Reglan) 10 mg qid, venlaxafene (Effexor), L-thyroxine.

Family History: Non-contributory.

Social History: Single, lives alone, unemployed. Denies tobacco or drug use, drinks a glass of wine per day.

Review of Systems: Denies recent fever, chills, sweats, dyspnea or chest pain. The review of systems is limited by the patient's brief answers and very limited recollection of details.

Physical Exam

General: This is a thin and unkempt woman in mild discomfort, appearing fatigued but pleasant and cooperating with the examination.

Vital Signs: Temperature 97.5 F (36 C). Pulse 112/min, regular. BP 177/110 mmHg, supine. Respirations 18/min. Oxygen saturation 100%.

HEENT: Normocephalic, no evidence of head trauma; sclera anicteric; oropharynx clear. Bedside fundoscopic examination was unremarkable. Neck:Supple; no carotid bruits, jugular venous distension or lymphadenopathy.

Chest: Clear to auscultation bilaterally.

Cardiovascular: Regular rate and rhythm without murmurs, rubs or gallops.

Abdomen: Soft, nontender, and nondistended. No hepatosplenomegaly.

Extremities: No cyanosis, clubbing or edema. No skin rashes or lesions noted.

Neurological Examination

Mental Status: The patient scores 17/30 on the Folstein Mini-Mental Status Examination (-1 for date, -1 for floor of hospital, -3 spelling "world" backwards, -2 recall, -1 for 3-step command, -3 read/write, draw).

Speech: Fluent with good repetition and comprehension. Labial, lingual and guttural sounds were normal.

Cranial Nerves:

Cranial Nerves

Findings

INot tested.
IIPupils: OD: 4mm, reactive to 2mm, OS: 6mm irregular and fixed. Visual acuity OD 20/200, OS 20/50. Visual fields are intact to confrontation.
III / IV / VIBilateral impairment of abduction, right greater than left. There is also partial impairment of adduction on the left. The patient reports subjective horizontal diplopia in all gaze positions. No ptosis is observed.
VPinprick and light touch intact and symmetric in all divisions of the face. Corneal reflex present bilaterally. Intact masseter and temporalis strength.
VIIFacial movements symmetrical with normal lip seal and eye closure.
VIIIHearing intact to finger rubs bilaterally.
IX / XPalate elevates symmetrically, uvula midline.
XISternocleidomastoid strength 5/5.
XIIMidline tongue protrusion without atrophy or fibrillations.

 

Motor: Normal muscle tone and bulk. Strength 5-/5 to 5/5 throughout and symmetrical in all muscle groups tested, except 4/5 in both iliopsoas.

Reflexes: 2+ at the biceps, 1+ triceps, brachioradialis and patellar, absent at the ankles. No crossed adduction was noted; plantar responses were flexor. No Hoffmann's, accentuated jaw jerk, glabellar, snout or palmomental reflexes were noted.

Sensation: Pinprick, light touch, vibration, and temperature appeared intact. Proprioception was mildly impaired at the toes and fingers bilaterally, but not in larger joints. Romberg maneuver was negative.

Coordination: Finger-nose-finger testing showed mild end-point dysmetria bilaterally. Mild dysmetria was present on heel-knee-shin testing bilaterally. Rapid alternating movements were slowed. Mild truncal ataxia was present.

Gait: Wide-based, unsteady and cautious; unable to walk without assistance. Unable to toe, heel or tandem walk.

Email comments: